Transcription of An error occurred. Flow Chart for Determining if an Error ...
1 An Error see Nurse Responsibilities when an Error Chart for Determining if an Error is a Minor IncidentMinor Incident = conduct by a nurse that may be a violation of the Texas Nursing Practice Act or a Board rule but does not indicate the nurse's continued practice poses a risk of harm to a patient or another person; synonymous with minor Error or minor violation of the Texas Nursing Practice Act or Board rule .Ye sReport the factors to the patient safety committee. Report to the CNO if no patient safety committee. Proceed to (d)(3).NoProceed to (e).(d)(2) Did factors beyond the nurse s control contribute to the incident?(d)(3) Would the Error still have occurred if there were no fac-tors beyond the nurse s control that contributed to the Error ?NoProceed to (e).If the Error only occurred because of the factors beyond the nurse s control and there was no contribution by the nurse (meaning the nurse does not have a deficit(s) in knowledge, judgment, skills, professional responsibility, or patient advocacy), then the Error may not be reviewable under this rule.
2 Proceed to (h). Please use this flow Chart in conjunction with Board Rule , Minor Incidents.(h) Some conduct falls outside the definition of a minor incident and must be reported to the nursing peer review committee or to the Board. This includes:(1) conduct that ignores a substantial risk that exposed a patient or other person to significant physical, emotional or financial harm or the potential for such harm;(2) conduct that violates the Texas Nursing Practice Act or a Board rule and contributed to the death or serious injury of a patient;(3) a practice-related violation involving impairment or suspected impairment by reason of chemical dependency, intemperate use, misuse or abuse of drugs or alcohol, mental illness, or diminished mental capacity;(4) a violation of Board Rule with actions that constitute abuse, exploitation, fraud, or a violation of professional boundaries.
3 Or(5) actions that indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's contin-ued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of (d)(1) Did a deficit(s) in the nurse s knowledge, judgment, skills, professional responsibility, or patient advocacy contribute to the incident?The Error may not reach the level of a minor incident. Proceed to (d)(2).Ye sYe sWill remediation address any identified deficit(s)?The Error may be a minor incident. A remediation plan must be developed to address the deficit(s) in accor -dance with facility policy. Components of the remediation plan, including the time frame for completion and evidence of completion, should be documented in accordance with (f).
4 (Report the nurse to the nursing peer review committee or the Board if the nurse does not complete the remediation.) Proceed to (d)(2).NoThe Error cannot be considered a minor incident. Report the nurse to the nursing peer review com-mittee, or report to the Board if there is no nursing peer review committee. Proceed to (d)(2). If the conduct does not meet the criteria in (h), then doc-ument the minor incidents according to (f). Report the nurse to the nurs-ing peer review committee, or report to the Board if there is no nursing peer review the minor incidents in-dicate a pattern of practice that demonstrates the nurse's continued practice poses a risk of harm?Ye s(e) Did the nurse have more than 1 minor incident (regardless of time frame)? Yes, <5 within a 12-month time periodYes, 5 within a 12-month time periodNoProceed to (h).NoProceed to (h).Ye sReport the nurse to the nursing peer review com-mittee or the Board.
5 Please see Nurse Responsibilities when an Error Error occurred.
